Indicators of Physical and Sexual Abuse

1. Indicators of Physical and Sexual Abuse Judith Race, CSW Coordinator of Direct Services Elderly Crime Victims Resource Center NYC Department for the Aging Adolfo Firpo, MD, MPA Director, Elder Mistreatment Training Project NYU Steinhardt School of Education, Division of Nursing

2. What is elder abuse? • Intentional behavior that results in the physical, sexual, emotional or financial harm or injury or neglect or abandonment of an older person (60+) by a family member, friend, fiduciary or caregiver NYC Elder Abuse Training Project

3. Types of Elder Abuse • Emotional/Psychological • Physical • Sexual • Financial • Neglect • Active or intentional • Inactive or unintentional NYC Elder Abuse Training Project

4. Physical Abuse of the Elderly • Use of physical force that may result in • Bodily injury • Physical pain • Impairment • Disease NYC Elder Abuse Training Project

5. Results of Physical Abuse • Wounds • Bruising • Burns • Syndromes: medicinal misuse; shaking • Fractures • Decubitis ulcers (bedsores) • Malnutrition • Dehydration NYC Elder Abuse Training Project

6. Difficulties in Detecting Abuse • Hard to distinguish between • A disease process • An injury • Often assumed that death was the result of old age • Physical inspection not always done • Deaths are often not evaluated in detail • Autopsies rarely performed (ageism) NYC Elder Abuse Training Project

7. Forensic Markers of Physical Abuse • Injuries • Not properly cared for • Delay in seeking medical treatment • Fractures • Unset broken bones • Note: some injuries and fractures may be the result of a medical condition (e.g., osteoporosis) and/or medication (e.g., Coumadin) NYC Elder Abuse Training Project

8. Medical Causes of Fractures • Age • Osteoporosis and other bone diseases • Poor nutrition • Vitamin D deficiency • Alcoholism • Age-related sex hormone deficiencies • Cancer that invades bone (e.g., osteosarcoma) NYC Elder Abuse Training Project

9. Sites of Fractures in the Elderly • Hip in >75 years old • Wrist in <75 years old • Common site of fracture with falls • Many use their hands to help break a fall • Head (face, teeth, cheekbones) • Trunk • Spine NYC Elder Abuse Training Project

10. Falls • Added difficulty in detecting abuse • Broken bones can be the result of a fall • Prevalence of falls • 30% of community-dwelling older persons • 50% of nursing home patients • Most persons who fall experience one to three falls a year • Note: Detailed examination of the patient, medical records, and/or collateral history from caregivers is needed to determine abuse NYC Elder Abuse Training Project

11. Facial Fractures • Teeth • Fracture or partial dislocation • Bony structures around the eyes (zygomatic arch) • Jaws (mandible and maxilla) • Facial fractures should raise suspicions of abuse NYC Elder Abuse Training Project

12. Bruising • In the older adult • Occurs more frequently • Resolves more slowly (may last for months) • Progression is normal • Recent bruising (reddish blue, blue, purple) • Older bruising (bluish green, greenish yellow, and brown) • Multiple bruises in different stages of healing may indicate abuse NYC Elder Abuse Training Project

13. Bruises Healing Stages 10 hrs 4-5 days 12 days NYC Elder Abuse Training Project

14. Sites of Bruising • In abuse victims, most often seen on • Knuckles and fingers • Face and neck • Chest wall • Abdomen • Buttocks • Palms and soles of feet NYC Elder Abuse Training Project

15. Bruising Distribution and Patterns Face & Neck Medial Surfaces NYC Elder Abuse Training Project

16. Patterns of Bruising • Pattern of bruising may suggest the cause • Bilateral • Parallel marks (tramline bruising) • Inside of arms and thighs • Clusters NYC Elder Abuse Training Project

17. Bruising Patterns • Bilateral • Different colors ranging from purple (recent) to yellow green (older) • Shape and Pattern • Facial distribution NYC Elder Abuse Training Project

18. Morphological Signs • Bruises or burns shaped like an object • Iron • Curling iron • Belt marks • Fingers • Cigarette burns • Rope burns (e.g., resulting from restraints) NYC Elder Abuse Training Project

19. Prevalence of Burns • In healthy adults: rare • In the frail elderly: rare in institutional settings • 70% of all burns are the result of abuse/neglect NYC Elder Abuse Training Project

20. Violent Shaking • Similar to shaken baby syndrome • Possible results in the elderly: • Whiplash • Detached retinas • Contusions • Brain atrophy • Brain hemorrhages NYC Elder Abuse Training Project

21. Other markers • Ruptured eardrums • Boxing the victim’s ears • Changes in hairstyle • Cover up for • Hair that may have been ripped out • Bruises NYC Elder Abuse Training Project

22. Decubitis Ulcers (bedsores) • The result of circulatory failure due to pressure resulting in dead tissue (necrosis) • May indicate that a bed-ridden patient is not being properly cared for and/or moved by the caregiver • Note: can also result from insufficient circulation due to medical conditions (e.g. diabetes) • Suspect neglect if: • Deep decubiti, multiple sites • Foul smelling dead tissue NYC Elder Abuse Training Project

23. Decubitus Ulcers Bed sore • Immobility • Skin over bony surfaces • Vasculature compression • Vascular insufficiency • Tissue necrosis • Inflammation • Infection • Sepsis • Shock NYC Elder Abuse Training Project

24. Prevalence of Decubitis Ulcers • In healthy adults: never • In the frail elderly, risk factors include: • Medical illness • Cognitive impairment • Incontinence • Poor nutrition • In abuse victims • More frequent illnesses means victims dependent on others for proper skin care • Neglect more likely NYC Elder Abuse Training Project

25. Skin Ulcers in Diabetic with Severe Vascular Insufficiency • General Condition • Edges • Centers • Smell • Surrounding Skin NYC Elder Abuse Training Project

26. Malnutrition • Poor health status due to the decreased intake of necessary nutrients • Poor diet • Malabsorption NYC Elder Abuse Training Project

27. Medical Causes of Malnutrition • Natural aging factors • Decline of smell and taste reducing appetite • Inappropriate medications, including psychotropic drugs • Medical conditions • (cancer, COPD, dementia, stroke, Parkinson’s Disease, disorders of the esophagus) NYC Elder Abuse Training Project

28. Other Causes of Malnutrition • Neglect (poor caregiving) • Self-neglect • Poor dentition • Poor oral hygiene • Loss of teeth • Depression • Loss of appetite NYC Elder Abuse Training Project

29. Causes of Appetite Loss in the Elderly • In the frail elderly: • Depression • Change in environment • Change in medical condition • Medication (over/under) • In the abuse victim • Inappropriate or excessive medications can affect swallowing and/or memory • Ignoring of cultural food preferences • Force feeding or other appropriate feeding NYC Elder Abuse Training Project

30. Dehydration • Loss of more fluids than are taken in • Elderly more prone • Often caused by medical illness • Neglect present if: • Inadequate fluids are offered or provided • Dehydration goes unrecognized for a long period of time by medical or nursing personnel NYC Elder Abuse Training Project

31. Symptoms of Dehydration • Dizziness • Dry mouth and nose • Decreased urine production NYC Elder Abuse Training Project

32. Possible Causes of Dehydration • Gastrointestinal illness (e.g., stomach flu) • Food poisoning • Alcohol overload • Dieting • Ignoring of thirst • Diabetes • Neglect or withholding of fluids • Too much caffeine NYC Elder Abuse Training Project

33. Misuses of Medications • Elders may misuse prescription drugs because • They lack capacity • They reject efforts by medical professionals to help them NYC Elder Abuse Training Project

34. Misuses of Medication • Medications can be used as a tool for abuse • Examples • Giving a person too much or too little of an indicated drug • Withholding a necessary medication • Administration of unnecessary or inappropriate medication NYC Elder Abuse Training Project

35. Misuses of Medications • Over-medication • To keep patients quiet and manageable • Under-medication or withholding of medication • Caregiver may use the drug him/herself • Unnecessary or inappropriate medication • Over/under-medication can result in medical or cognitive impairment NYC Elder Abuse Training Project

36. Sexual Abuse of the Elderly • Non-consensual sexual contact of any kind • Sexual contact with any person incapable of giving consent • Elderly are more vulnerable due to • Cognitive impairment • Physical inability to protect oneself NYC Elder Abuse Training Project

37. Sexual Abuse • Includes but is not limited to • Unwanted touching • All types of sexual assault or battery such as • Rape • Sodomy • Coerced nudity • Sexually explicit photography • Difficult to detect in the elderly • Difficult for victim to discuss • Older adults are vulnerable to sexual abuse NYC Elder Abuse Training Project

38. Physical Forensic Markers of Sexual Abuse • Torn, stained, bloody underclothing • Difficulty in walking, standing and/or sitting • Changes in bowel movement or bladder activity • Pain, itching, bruising, burning in genital area • Unexplained venereal disease NYC Elder Abuse Training Project

39. Physical Forensic Markers of Sexual Abuse • Bruising • Palate (hard plate at roof of mouth) • Uvula (appendage to palate) • Genital area (75% of those who have been sexually abused) • Sexually transmitted disease • Signs of restraint NYC Elder Abuse Training Project

40. Behavioral Forensic Markers of Sexual Abuse • Withdrawal • Fear • Depression • Anger • Insomnia • Increased interest in sexual matters • Increased sexual or aggressive behavior NYC Elder Abuse Training Project

41. Prevalence of Sexual Abuse • More frequent in the cognitively impaired and those needing help with ADLs and/or IADLs NYC Elder Abuse Training Project

42. Important Information to Consider • Medical history • Medical records from primary care physician • Functional History • Are there any physical limitations? • What are the victim’s ADLs/IADLs? NYC Elder Abuse Training Project

43. Important Information to Consider • Mental/Cognitive capacity • Other issues • Recent illnesses • Victim’s attitudes, feelings • Does the victim have regular check-ups? • Doctor and/or hospital hopping NYC Elder Abuse Training Project

44. Working with an Elderly Victim of Sexual Abuse • Is the victim able to give consent? • Especially important in sexual assault cases • Could the suspect reasonably have believed that the victim understood and was able to give legal consent? NYC Elder Abuse Training Project

45. Questions for the Victim • Ask: • “Do you have other bruises, burns, or clusters of bruises on your body?” (May have come from repeated abuse) • “How often do you go to the doctor?” • “How many different doctors do you see?” • “How often have you been to the emergency room in the past year?” • “How many different hospital emergency rooms have you visited in the past year?” • Are the answers consistent with what you see? NYC Elder Abuse Training Project

46. Important Steps in Detecting Abuse • Explore the use of medications • Side effects • Interactions • Medications can be used as a tool for abuse • Exploring the use of multiple medications • Determine cognitive functioning and functional dependency of victim • Refer to a psychiatrist for evaluation • (e.g., Folstein mini-mental, Geriatric Depression Screen, PTSD symptom scale) NYC Elder Abuse Training Project

47. Photo credits • Slide 15 left: http://www.elderabusecenter.org/default.cfm?p=basics.cfm • 15 mid, right: http://www.nursing-home-abuse.net/images/bruising.jpg • 17,top: http://www.ctv.ca/servlet/ArticleNews/ story/ CTVNews/1076082613040_71491813/?hub=WFive • 17, bottom: http://www.elderabusecenter.org/default.cfm?p=basics.cf • 24: http://www.moondragon.org/images/bedsoresslowgh.jpg • 26 left:: http://www.woundcarefelpline.com/whcimages/page123.jpg • 26 right: http://ww.vein.cniPOP_Know/image/ulcers.jpg NYC Elder Abuse Training Project